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Pregnancy increases the risk of pulmonary embolism. Computed tomography pulmonary angiography (CTPA) is used for diagnosis. CT generates ionising radiation, and thus, abdominal shielding may be used. This phantom study investigated the effects of patient shielding and scan length reduction on the fetal and maternal ionising radiation dose from CTPA. The absorbed dose to the fetus was measured using thermoluminescent dosemeters. Estimated effective doses to the pregnant patient were based on the dose-length products. Shielding increased both the effective dose to the patient by 47% and the mean absorbed dose to the fetus (0.10 vs. 0.12 mGy; p

Background: Although ischaemic stroke with malignancy occasionally occurs, the mechanisms of stroke in such cases have not been investigated in detail. Objective: To examine the mechanisms of ischaemic stroke with malignancy, particularly in relation to right-to-left shunt (RLS). Methods: Consecutive patients with ischaemic stroke within 24 h of stroke onset were prospectively studied. Contrast saline transcranial Doppler examination was carried out for all patients, to investigate the presence of RLS. When patients with stroke had RLS, deep venous thrombosis (DVT) or pulmonary embolism was assessed to diagnose paradoxical brain embolism. Results: Participants comprised 184 consecutive patients (115 men and 69 women) with a mean (standard deviation (SD)) age of 73 (11.8) years and mean (SD) National Institutes of Health Stroke Scale (NIHSS) score of 8 (7.4). RLS was detected in 32 of 184 (18%) patients. Malignancy was present in 11 (5%) patients. RLS was more frequent in patients with malignancy than in patients without malignancy (55% v 15%, respectively; p = 0.001). All six patients with RLS and malignancy displayed DVT or pulmonary embolism with severe disability (modified Rankin Scale 4–5) before stroke onset. Conclusion: Paradoxical brain embolism should be considered to be an important mechanism in patients with stroke and malignancy.

Patients with cancer who develop venous thromboembolism (VTE) are at elevated risk for recurrent thrombotic events, even during anticoagulant therapy. The clinical picture is further complicated because these patients are also at increased risk of bleeding while on anticoagulants. In general, there are four key goals of treatment for VTE: preventing fatal pulmonary embolism (PE); reducing short-term morbidities associated with acute leg or lung thrombus; preventing recurrent VTE; and preventing the long-term sequelae of VTE (e.g., post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension). A fifth goal – minimising the risk for bleeding while on anticoagulation – is particularly warranted in patients with cancer. Traditionally, pharmacological treatment of VTE has two phases, with the transition between phases marked by a switch from a rapid-acting, parenterally administered anticoagulant (such as unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux) to an oral vitamin K antagonist (e.g., warfarin). Recent clinical trials of established agents and the advent of new pharmacological options are changing this paradigm. Low-molecular-weight heparin continued for 6 months is more effective than warfarin in the secondary prevention of VTE in cancer patients without increasing the risk of bleeding and is now the preferred treatment option. Given the impact of VTE on short-term and long-term outcomes in patients with cancer, a group of health-care providers based in the United Kingdom gathered in London in 2009 to discuss recent data on cancer-associated thrombosis and to evaluate how these recommendations can be integrated or translated into UK clinical practice. This article, which is the third of four articles covering key topics in cancer thrombosis, focuses on treatment and secondary prevention of VTE in cancer patients.

Purpose Pulmonary embolism (PE) has a significant associated morbidity and mortality. The role of diagnostic imaging in PE is being increasingly undertaken by computed tomography pulmonary angiography (CTPA). An advantage of CTPA is its ability to simultaneously provide information on the lung parenchyma, mediastinum, pleural spaces, and chest wall. A sample of CTPAs was therefore reviewed to identify the types of additional pathology demonstrated. Materials and Methods One hundred and ninety-eight CTPA examinations were retrospectively reviewed. A record was made of the presence of PE and any additional pathology, with particular interest given to “incidental” pathology, or pathology that was unsuspected but which was significant enough to change the patient's management. A note was also made as to the adequacy of the study. D-Dimer values were recorded when available. Results PE was demonstrated in 56 studies (28.3%). Additional pathology was seen in 112 studies (56.6%), of which 17 were categorised as incidental. These included multiple pulmonary nodules, solitary lung lesions, destructive bony lesions, pancreatitis, a solid renal mass, mesothelioma, reactivated pulmonary tuberculosis, recurrent bronchial carcinoma, pulmonary fibrosis, an SVC filling defect, and a compression fracture of T10. Conclusion The prevalence of PE in our sample was 28.3%, compared with a reported prevalence, mainly by pulmonary angiography, of between 19% and 79%. Secondary findings were found in 56.6% of scans, with completely incidental findings demonstrated in 17 patients (9%). This emphasizes the usefulness of CTPA in providing additional diagnostic information and alternative diagnoses in patients with suspected PE.